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Cardiovascular II Final Exam > Valvular Heart Disease (Johnston) > Flashcards

Valvular Heart Disease (Johnston) Flashcards

1
Q

Grading of murmurs

A

I: so soft, barely heard
II: soft but easily heard
III: moderately loud, readily heard NO palpable thrill
IV: Palpable thrill, very loud
V: Palpable thrill, very loud even with stethoscope barely on chest wall
VI: Palpable thrill, can hear when you walk in room

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2
Q

Most common conditions associated with valvular disease and decline in what disease?

A
  • MC: Degenerative (senile calcification), Myxomatous degernation (MVP), Congenital (bicuspid aortic valve)
  • Decline in incidence of rheumatic valvular disease (RVD)
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3
Q

Valvular HD leads to

A

-Pressure or volume overload

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4
Q

Stenosis implies

A
  • impeded foward flow
  • stenotic, sclerosis, fibrosis, calcification
  • Leads to pressure overload; hypertrophy and heart failure (HF)
  • Example: Aortic Stenosis, Mitral Stenosis
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5
Q

Regurgitation implies

A
  • Failure to close adequately (leaks):
  • reversal of flow
  • insufficiency, incompetence
  • leads to volume overload; dilates
  • Example: AI, MR
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6
Q

VHD can be

A

-congenital or acquired

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7
Q

Valvular dysfunction depends on? Examples?

A
  • depends on tempo of disease onset (acute/chronic)
  • Ex: Infective endocarditis–aortic cusp destruction leads to ACUTE AORTIC INSUFFICIENCY
  • Ex: RHD complications develop over years; compensatory mechanism (CHRONIC)
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8
Q

RHD

A
  • Due to RF
  • RF–caused by group A strep infection (pharyngitis) virtually only cause of acquired MS (can be congenital)
  • Jones major criteria: inflammation of heart muscle–myocarditis, pericarditis; migratory polyarthritis (large joints)–example: knees, hips, Subcutaneous nodules–painless over bone and tendon, Sydenhams chorea (st. vitus’s dance) rapid purposeless movement of face and arms; erythema marginatum
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9
Q

Jones minor criteria for RF

A
  • Fever
  • Arthralgia
  • Increased Sed rate or CRP
  • Leukocytosis
  • ECG–prolonged PR
  • Elevated ASO titer or anti DNase B
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10
Q

Diagnosis of RF

A
  • two major criteria OR

- One major and 2 minor criteria

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11
Q

Mitral stenosis

A
  • DIASTOLIC MURMUR! Best heard over APEX of heart
  • Normal mitral valve orifice is 4-6 cm
  • Narrowing leads to increased Left AV pressure gradient
  • LAE (a fib, pul vascular changes, RVH)
  • Orifice 1cm or less is severe that leads to pul HTN, RVF
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12
Q

Mitral stenosis symtoms

A
  • 4th decade
  • Dyspnea on exertion
  • cough, orthopnea, PND, pulmonary edema, hemoptysis, arterial emboli
  • A fib
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13
Q

Ortner syndrome

A
  • Hoarsness d/+ compression of left recurrent laryngeal nerve bc Left atrium is so big
  • Paralysis of vocal cord
  • Associated with MITRAL STENOSIS!!
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14
Q

Mitral stenosis physical exam

A
  • Malar flush: ruddy cheeks, blue facies
  • Increase S1; opening shapes (OS) after S2
  • Rumbling, diastolic murmur
  • LOW PITCHED; BEST HEARD AT APEX
  • USE BELL
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15
Q

Mitral stenosis treatment

A
  • Anticoagulant if in atrial fibrillation
  • Percutaneous balloon valvuloplasty MVR (replacement)
  • Progressive symptoms–possible RVF
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16
Q

Why could patient that has MS develop progressive symptoms leading to RVF?

A
  • Because everything backing up
  • Left atrial pressure builds up, vascular resistance increases–>pulm HTN–>pulmonary artery pressure increases–>causing RVF (hepatomegalia, ascites, peripheral edema)
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17
Q

Cause of Mitral stenosis

A

-Most likely RHD!!

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18
Q

Most common etiology of Mitral regurgitation

A
  • Mitral valve prolapse

- May also be caused by mitral annular calcification

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19
Q

Causes of acute mitral regurgitation

A
  • Rupture of chrodae tendinae
  • Rupture of papillary muscle
  • Ischemic papillary muscle dysfunction due to CAD/MI
  • Infective endocarditis; valve perforation
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20
Q

Second most common cause of mitral regurgitation

A

-CAD/MI–can lead to papillary muscle dysfunction and mitral regurg

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21
Q

Acute vs Chronic Mitral regurg

A
  • Acute MR: increased LA pressure abruptly; pulmonary edema, LVF
  • Chronic MR–generally well compensated
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22
Q

Mitral regurg symtoms

A
  • Asymptomatic for years
  • may have fatigue, DOE
  • Acute MR: volume overload–orthopnea, PND, RHF/ LHF
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23
Q

What does a mitral regurg sound like on PE? systolic or diastolic?

A
  • systolic murmur
  • Blowing, prominent at apex; radiates into left axilla
  • Loudness of murmur correlates with severity
  • Decreased S1 or normal; may have systolic click
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24
Q

Treatment of MR

A
  • Vasodilators–reduces after load
  • Decrease resistance to flow
  • ACEI–chronic MR
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25
Q

MVP and Mitral regurg

A
  • One or both mitral leaflets will prolapse into LA during systole to cause MR
  • MVP ratio is 7:1 female
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26
Q

MVP associated with what disease

A

-Marfan’s/skeletal changes

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27
Q

Symptoms of MVP

A
  • Asymptomatic to arrhythmias (SVT, PVC, VT)
  • Sometimes will see chest pain and syncope
  • Systolic murmur; may have systolic click
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28
Q

Treatment of MVP

A
  • If hyperadrenergic state (anxious, palpitations), consider beta blocker
  • Valve repair favored over replacement
29
Q

How to confirm MR in patient

A
  • Heart Holter monitor!!

- Other tests: Echo, ECG, TSH, Free T4, CXR

30
Q

Tx of MVP and thyroid disorder

A
  • Beta blocker for hyper adrenergic state

- Regulate thyroid meds

31
Q

Aortic stenosis Etiology

A
  • Degenerative (calcific or senile)
  • Congenital bicuspid aortic valve (BAV)
  • 1% of population born with BAV
  • Rheumatic or post inflammatory scarring
  • Normal AoV is 4 cm
32
Q

Aortic stenosis–where on heart? What does it sound like?

A
  • 2nd intercostal space RSB

- Harsh, raspy, systolic murmur typically radiates into suprasternal notch up into the carotids

33
Q

Pathophysiology of AS

A
  • Obstruction leads to PRESSURE overload; LVH, increase LVED pressure
  • Gradient across valve–the more the obstruction, the higher the gradient across the valve
34
Q

Severe AS if

A

AoV is less than 1 cm

35
Q

Symptoms of AS

A

-6th decade: exertional dyspnea, angina, syncope, heart failure

36
Q

AS prognosis

A
  • Without treatment prognosis is poor

- Without treatment most will die within 3 years of developing syncope and within 2 years of onset of HF

37
Q

Hallmarks for AS

A

-ANGINA, SYNCOPE AND DYSPNEA!!!!

38
Q

Physical Exam AS

A

-Narrow pulse pressure; decreased SV and systolic pressure
-Delayed pulses–Parvis/Tardus
-Systolic murmur
-Harsh 2nd ICS RSB; radiates into supra sternal notch/carotids
-

39
Q

Gallvardin phenomenon

A
  • associated with AS

- Murmur radiates into apex (like MR)

40
Q

ECG associated with AS

A

-LVH (high voltage QRS in V6) with strain pattern

41
Q

Treatment for AS

A

-Percutaneous balloon valvuloplasty–temporary AVR (aortic valve replacement)

42
Q

Tests needed to diagnose AS

A
  • Echo, ECG, CXR, Cardiac enzymes

- Echo–AoV area 1 cm–Diagnosis severe AS

43
Q

Aortic Regurg causes

A
  • Due to leaflet abnormalities (bicuspid AoV, IE)
  • Due to aortic root abnormalities (Marfans, aortic dissection, aging, HTN)
  • may also be from vegetations
44
Q

Causes of acute AR

A 
IE
aortic dissection
BAV
Acue pulmonary edema
cardiogenic shock
45
Q

Causes of chronic AR

A
  • Syphillis
  • Ankylosing spondylitis–seronegative orthropathy
  • develops over time and will see dyspnea, orthopnea, PND, chest pain!
46
Q

AR systolic or diastolic? Heard where?

A
  • soft DIASTOLIC murmur

- 2nd intercostal space, LSB

47
Q

Pathophysiology AR

A

-Volume overload can increase LVEDV, LVH, left sided HF

48
Q

Symptoms of AR

A

-Depends on rapidity of onset

49
Q

Physical exam findings of AR

A
  • Wide pulse pressure–ex: 140/60
  • De Musset sign–head bobs bc of forceful systolic beat
  • Corrigans pulse-rapid water hammer pulse
  • Quinckes pulse-pulsations at nail bed
  • Traube’s sign–pistol shot type of sound
  • Durozrey’s sign-when compressing artery hear to and fro murmur over those arteries
  • Hills sign–systolic BP higher in legs than in arm
  • Bisferious pulse–double peak to pulse
  • Meullers sign–can see uvula at back of throat moving with each systolic beat
50
Q

Physical exam AR–sounds, found where

A

Diastolic

  • decrescendo murmur
  • 3rd ICS LSB
  • systolic murmur usually present but soft
  • Austin Flint murmur; Can mimic MS
51
Q

Hallmark for AI

A
  • DIASTOLIC MURMUR
  • 3RD ICS LSB
  • sometimes also associated with systolic murmur
  • can mimic MS–called Austin Flint murmur
52
Q

Treatment for AR

A
  • ARB–Decreases after load to decrease regurg volume

- Surgery AoVR when symptomatic or EF less than 55%

53
Q

CT of chest used for

A

-Aortic dilation

54
Q

Tricuspid stenosis associated with

A
  • Mitral stenosis
  • TR
  • Rheumatic Heart disease
55
Q

Pathophysiology of tricuspid stenosis

A

-Prominent A wave in JVP–ascites, hepatomegalia (may pulsate)

56
Q

Tricuspid stenosis—what kind of murmur? Systolic or diastolic?

A

-Diastolic murmur LSB; increase with inspiration (Carvallo’s sign) and decrease with expiration and valsalva

57
Q

Tricuspid Regurgitation associated with?

A
  • Pulmonary hypertension

- Inferior MI/RV infarction

58
Q

Pathophysiology of TR

A

-Prominent V wave in JVP

59
Q

TR sounds like? Systolic or diastolic?

A

-Blowing systolic murmur LSB; increases with inspiration (Carvallo’s sign)

60
Q

Causes of pulmonary stenosis

A
  • Atresia

- Congenital

61
Q

Pulmonary stenosis can cause

A

-Angina and syncope

62
Q

Auscultation of pulmonary stenosis

A
  • systolic murmur, ejection click

- 2nd-3rd ICS, LSB/ radiates toward left shoulder and increases on inspiration/RVH

63
Q

Pulmonary stenosis associated with what disorders

A

-TOF or TGA

64
Q

Pulmonary stenosis treatment

A

-May require balloon commissurotomy if pressure gradient > 50mm Hg

65
Q

Pulmonic regurgitation (PR or PI)–causes? Sounds like? Systolic or diastolic?

A
  • Most cases are due to pulmonary HTN

- Diastolic blowing murmur 2nd SB (Graham Steell)

66
Q

Systolic murmurs:

A
  • Mitral regurg (MVP)
  • Tricuspid Regurg
  • Aortic Stenosis
  • Pulmonary stenosis
  • VSD
  • Aortopulmonary shunts (early, mid, late, holosystolic/pansystolic)
67
Q

Diastolic murmurs:

A
  • Aortic Regurg
  • Pulmonary Regurg
  • Mitral stenosis
  • Tricuspid stenosis
  • Atrial myxoma
68
Q

Continuous murmurs

A
  • PDA–machinery
  • AV fistula
  • ASD with high LA pressure
  • Coarctation

Cardiovascular II Final Exam (13 decks)

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